本文選題：重癥患者 + 萬(wàn)古霉素��； 參考：《吉林大學(xué)》2017年碩士論文

【摘要】：目的:重癥患者萬(wàn)古霉素血清藥物濃度的影響因素復(fù)雜多樣,腎功能正常與否、血漿蛋白水平等均可影響萬(wàn)古霉素的藥代動(dòng)力學(xué)。本研究旨在分析不同腎功能及其病理狀態(tài)下萬(wàn)古霉素的代謝特點(diǎn),探討重癥患者萬(wàn)古霉素藥代動(dòng)力學(xué)的影響因素及給藥方案。方法:選取吉林大學(xué)第二醫(yī)院2016年01月至2016年12月入住ICU病房使用萬(wàn)古霉素治療的重癥感染患者,收集患者的性別、年齡、身高、體重、APACHEⅡ評(píng)分、血肌酐值、胱抑素C、白蛋白,尿量、萬(wàn)古霉素給藥量、血清谷濃度等指標(biāo)。根據(jù)肌酐清除率水平分為腎功能正常組(CCr≥60ml/min·1.73m2)及腎功能減退組(CCr60ml/min·1.73m2),再根據(jù)萬(wàn)古霉素血清谷濃度水平分為谷濃度10mg/L組、谷濃度10~20mg/L組及谷濃度20mg/L組,分析不同腎功能及不同血清谷濃度組年齡、白蛋白、尿量、胱抑素C、CCr、給藥量及APACHEⅡ評(píng)分的差別及對(duì)谷濃度的影響。結(jié)果:腎功能減退組有40.91%(9次)萬(wàn)古霉素血清谷濃度10mg/L,27.27%(6次)血清谷濃度在10~20mg/L之間,31.82%(7次)血清谷濃度20mg/L;腎功能正常組有50.00%(12次)萬(wàn)古霉素血清谷濃度10mg/L時(shí),37.50%(9次)血清谷濃度在10~20mg/L之間,12.50%(3次)血清谷濃度20mg/L。腎功能減退組年齡、胱抑素C、APACHEⅡ評(píng)分高于腎功能正常組,且差異有統(tǒng)計(jì)學(xué)意義(t_(年齡)=-1.31,P_(年齡)=0.198;t胱抑素C=-5.68,P胱抑素C=0.000;t APACHEⅡ=-2.79,P APACHEⅡ=0.008);腎功能減退組白蛋白、尿量、給藥量均低于腎功能正常組,并有統(tǒng)計(jì)學(xué)差異(t_(白蛋白)=2.63,P_(白蛋白)=0.011;t_(尿量)=2.63,P_(尿量)=0.012;t_(給藥量)=5.07,P_(給藥量)=0.000)。腎功能減退組的萬(wàn)古霉素平均谷濃度水平較腎功能正常組高,但二者差異無(wú)統(tǒng)計(jì)學(xué)意義(t_(谷濃度)=-1.13,P_(谷濃度)=0.263)。腎功能減退時(shí)不同谷濃度組實(shí)際給藥量與推薦給藥量無(wú)明顯差別,腎功能正常時(shí)不同谷濃度組的實(shí)際給藥量與推薦劑量也無(wú)統(tǒng)計(jì)學(xué)差異。腎功能減退時(shí)谷濃度10mg/L組白蛋白大于谷濃度10~20mg/L組,胱抑素C小于谷濃度10~20mg/L組(t_(白蛋白)=4.37,P_(白蛋白)=0.001;t胱抑素C=-2.83,P胱抑素C=0.014),肌酐清除率無(wú)明顯差異(t CCr=0.58,PCCr=0.574);谷濃度20mg/L組與谷濃度10~20mg/L組相比,蛋白與胱抑素C有差異(t_(白蛋白)=3.56,P_(白蛋白)=0.004;t胱抑素C=-2.35,P胱抑素C=0.039),肌酐清除率無(wú)統(tǒng)計(jì)學(xué)差異(t CCr=1.08,PCCr=0.303);腎功能正常時(shí)谷濃度10mg/L組與谷濃度10~20mg/L組相比尿量存在顯著差異(t_(尿量)=2.29,P_(尿量)=0.034),年齡、白蛋白、胱抑素C、CCr及APACHEⅡ評(píng)分均無(wú)明顯差異(t_(年齡)=-1.09,P_(年齡)=0.290;t_(白蛋白)=0.24,P_(白蛋白)=0.813;t胱抑素C=-1.33,P胱抑素C=0.198;t CCr=1.15,PCCr=0.262;t APCHEⅡ=-0.46,P APACHEⅡ=0.650);谷濃度20mg/L組與谷濃度10~20mg/L組相比年齡、白蛋白、尿量、胱抑素C、CCr及APACHEⅡ評(píng)分均無(wú)統(tǒng)計(jì)學(xué)差異(t_(年齡)=-0.56,P_(年齡)=0.586;t_(白蛋白)=0.11,P_(白蛋白)=0.916;t_(尿量)=-0.21,P_(尿量)=0.835;t胱抑素C=-0.98,P胱抑素C=0.350;t CCr=-0.37,PCCr=0.717;t APACHEⅡ=-0.02,P APACHEⅡ=0.982)。將影響萬(wàn)古霉素血清谷濃度的因素進(jìn)行多重線性回歸分析結(jié)果顯示:尿量、CCr及給藥量對(duì)萬(wàn)古霉素血清谷濃度的影響有統(tǒng)計(jì)學(xué)意義(t_(尿量)=-2.90,P_(尿量)=0.006;t CCr=-0.092,PCCr=0.005;t_(給藥量)=3.859,P_(給藥量)=0.000),而年齡、白蛋白、胱抑素C、APAHCEⅡ評(píng)分均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論:1.在腎功能減退時(shí),低白蛋白可導(dǎo)致萬(wàn)古霉素血清谷濃度升高;在腎功能正常時(shí),尿量與萬(wàn)古霉素谷濃度呈負(fù)相關(guān)。2.肌酐清除率、給藥量、尿量均對(duì)萬(wàn)古霉素的谷濃度有影響,重癥患者應(yīng)用萬(wàn)古霉素治療時(shí),在達(dá)到穩(wěn)定的治療藥物濃度前,應(yīng)前移首次血藥濃度監(jiān)測(cè)時(shí)間,增加血藥濃度監(jiān)測(cè)頻率。
[Abstract]:Objective: the influencing factors of patients with severe vancomycin serum concentration of complicated renal function is normal or not, the level of plasma protein can influence the pharmacokinetics of vancomycin. The purpose of this study is to analyze the metabolic characteristics of different renal function and pathological state of vancomycin, and to explore the influencing factors of patients with severe vancomycin pharmacokinetics and dosing regimen.: the second hospital of Jilin University were selected from 2016 01 to December 2016 admitted to the ICU ward using vancomycin in the treatment of severe infection, collect the patient's gender, age, height, body weight, APACHE score, serum creatinine, Cystatin C, albumin, urine volume, vancomycin dosage, serum concentration and other indicators. According to creatinine clearance rate divided into normal renal function group (CCr = 60ml/min, 1.73m2) and renal dysfunction group (CCr60ml/min, 1.73m2), according to the trough serum vancomycin concentration The level of 10mg/L group was divided into the valley, valley concentration in 10~20mg/L group and 20mg/L group of different concentration, renal function and serum concentration of different age group, albumin, urine volume, serum cystatin C, CCr dosage and APACHE score difference and the influence of the valley concentration. Results: renal dysfunction group 40.91% (9) of vancomycin serum concentration of 10mg/L, 27.27% (6) serum concentration between 10~20mg/L, 31.82% (7) serum concentration of 20mg/L in normal renal function group; 50% (12) of vancomycin serum concentration of 10mg/L, 37.50% (9) serum trough concentration between 10~20mg/L, 12.50% (3) 20mg/L. concentration decreased group renal function serum cystatin C, age, APACHE score higher than that of the normal renal function group, and the difference was statistically significant (t_ (age) =-1.31, P_ (age) =0.198; t P, Cystatin C=-5.68, Cystatin C=0.000; t APACHE P APACHE =0.008 II =-2.79, II); renal function Can decreased group albumin, urine volume, the dosage was lower than that of the normal renal function group, and there was significant difference (t_ (albumin) =2.63, P_ (albumin) =0.011; t_ (=2.63, P_ (urine) urine volume (=0.012); t_ =5.07, P_ dosage) (dose) =0.000) vancomycin. Renal dysfunction group average concentration levels than normal renal function group, but no statistically significant difference between the two groups (t_, =-1.13, P_ (concentration) (Gu Nongdu) =0.263). Renal dysfunction at different dosage and concentration of the actual Valley Group recommended dosage had no significant difference, normal renal function when different the minimum concentration of group dosage and the recommended dose had no significant difference. The decline of renal function when the concentration of 10mg/L group is greater than the valley Valley albumin concentration of 10~20mg/L group, C 10~20mg/L group is less than the minimum concentration of cystatin (t_ (albumin) =4.37, P_ =0.001 t (albumin); cystatin C=-2.83, Cystatin P C=0.014), creatinine clearance rate was no significant the difference (t CCr=0.58, PCCr=0.574); compared with the valley concentration 20mg/L group and 10~20mg/L group concentration, protein and cystatin C difference (t_ (albumin) =3.56, P_ =0.004 t (albumin); cystatin C=-2.35, Cystatin P C=0.039), creatinine clearance rate showed no significant difference (t CCr=1.08, PCCr=0.303); normal renal function concentration 10mg/L group and 10~20mg/L group compared to the amount of urine concentration had significant difference (t_ =2.29, P_ (urine) (urine) =0.034), age, albumin, Cystatin C, there were no significant difference between the CCr and APACHE score (t_ (age) =-1.09, P_ (age) =0.290; t_ (albumin) =0.24, P_ =0.813 t (albumin); cystatin C=-1.33, P t CCr=1.15, Cystatin C=0.198; PCCr=0.262; t APCHE P APACHE =0.650 II =-0.46, II); trough concentration of 20mg/L age group compared with 10~20mg/L group, the minimum concentration of albumin, urine volume, serum cystatin C, were no significant difference between the CCr and APACHE score (t_ (age) =-0.56 P_ (age =0.). 586; t_ (albumin) =0.11, P_ (albumin) =0.916; t_ (=-0.21, P_ urine volume) (urine) =0.835; t cystain C=-0.98, P t CCr=-0.37, Cystatin C=0.350; PCCr=0.717; t APACHE P APACHE II =-0.02 II =0.982). Serum concentration of vancomycin will influence factors of multiple linear the results of regression analysis showed that the amount of urine, CCr and dosage of vancomycin serum concentration was statistically significant (t_ =-2.90, P_ (urine) (urine) =0.006; t CCr=-0.092 PCCr=0.005; t_, =3.859, P_ (dose) (dose) =0.000), age, albumin, Cystatin C and the APAHCE score were not statistically significant. Conclusion: 1. in renal insufficiency, low albumin can lead to elevated serum concentration of vancomycin; in normal renal function, urine volume and vancomycin trough concentrations were negatively correlated.2. creatinine clearance rate, dosage, concentration of vancomycin urine were influential, critically ill patients should In the treatment of vancomycin, the monitoring time of the first blood drug concentration should be moved forward before reaching a stable therapeutic drug concentration, and the monitoring frequency of the blood concentration should be increased.

【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R969

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